Medical billing in today's age can be complex for numerous reasons, one of which is the use of a multi-payer system where insurance companies are responsible for a portion of the costs for a patient and the patient is responsible for the remainder. When a medical claim or bill is issued, it is frequently coded with the proper medical billing codes and then it is sent to the patient's insurance company for review and processing. If there is an error in the medical coding, or if there is another issue with the bill, the insurance company may deny coverage. When this occurs, the medical office issuing the bill or the patient may need to contact the insurance company and determine why coverage was rejected and find out how to correct the bill. Due to the high volume of medical bills in insurance company processing departments, it can take an undesirable amount of time on the phone with a claims representative of the insurance company to identify the problem and correct it.
Because of the complexity and inefficiencies in this process, medical offices often rely on medical claims management companies to manage their billing and coordinate with the insurance companies for unpaid claims. The medical offices provide the medical claims management companies with their outstanding bills and the medical claims management companies call the insurance companies to identify the reason for the unpaid bill. Due to the high volume of claims, however, the insurance companies often limit the number of medical claims that can be discussed during one phone call. And, in many instances there is a wait time to speak to a representative at the insurance company, so it may only be possible for an employee at the medical claims management company to make 2-4 calls per hour. Thus, there is a practical ceiling of productivity for resolving unpaid medical claims.
Moreover, the inefficiency with this process is further complicated by the fact that medical claims are time sensitive. If the claim is not properly submitted to the insurance company within a certain period of time, commonly 90 days, the insurer can refuse to pay the claim. Similarly, medical claims are naturally for various monetary amounts, and the higher amounts are often more important to process than lower amounts. For example, given a claim for $30 and a claim for $3,000, both of which are nearing the end of the time period for processing, the medical office would certainly desire to process the larger claim first. However, it can be difficult to organize and manage the claims in such a way to handle the most important claims first, namely due to the lack of a management system for instructing the personnel at the medical claims management company which claims to process first.
Thus, for at least these reasons, a heretofore unaddressed need exists in the industry to address the aforementioned deficiencies and inadequacies.